A prospective cohort study of presenteeism and increased risk of unemployment among Japanese workers during the COVID-19 pandemic

Abstract Objectives: Presenteeism adversely affects workers’ quality of life, leading to further deterioration of their health and affecting their ability to continue working. Unemployment is one of the most serious consequences for workers experiencing presenteeism. A worker’s ability to work depends on the degree of mismatch between their health status and job demands and work factors. The COVID-19 pandemic has affected workers’ experiences of presenteeism as well as their employment status. We examined the association between presenteeism and risk of job resignations and unemployment among Japanese workers during the COVID-19 pandemic. Methods: A prospective study of 27 036 internet monitors was conducted, starting in December 2020, with 18 560 (68.7%) participating in the follow-up by December 2021. The Work Functioning Impairment Scale (WFun) was used to measure the degree of work function impairment. Results: The group with the highest WFun scores had higher odds ratios (ORs) for both retirement and unemployment for health reasons than the group with the lowest WFun scores. ORs were 2.99 (95% CI, 2.48-3.62; P < .001) and 1.82 (95% CI, 1.65-2.00; P < .001), respectively. Conclusions: Workers with work functioning impairment are at increased risk of resignation or unemployment. Management strategies for workers with work functioning impairment are needed to reduce their disadvantages in employment.


Introduction
Presenteeism is a condition in which a worker continues to work while in an unhealthy condition. 1Two aspects of presenteeism are of public health concern.First, continuing to work while in poor health results in a loss of productivity, with consequential losses for the business. 2In many regions, employers are generally at least partially responsible for the costs of health and medical care for their workers.They are therefore interested in the allocation of resources to invest in health support for workers, taking into account the direct costs of health and medical care as well as indirect costs such as reduced labor productivity and absenteeism. 3,4econd, presenteeism adversely affects workers' quality of life, leading to further deterioration of their health and affecting their ability to continue working. 5,66][7][8] Eventually, the worker may find it difficult to continue in employment and be excluded from the labor market. 6,9This has a significant impact on the economic situation of not only the workers themselves but also their families, leading to an increased burden on social security.
Viewed with the latter perspective, unemployment is one of the most serious consequences for workers experiencing presenteeism.A worker's ability to work depends on the degree of mismatch between their health status and job demands and work factors. 10,11The extent to which an individual has difficulty working due to health reasons depends not only on the type and severity of disease, but also on a variety of factors, including the type of work, support of supervisors and co-workers, and the company's health climate.A decrease in the worker's ability to perform his or her job duties results in difficulties in remaining employed. 12,13Previous studies have reported a relationship between presenteeism and unemployment risk for several specific diseases, including depression, 14 rheumatoid arthritis, 15 type 2 diabetes, 16 and spondyloarthritis. 17However, despite the widely discussed work productivity of presenteeism, few studies have examined the association between presenteeism and unemployment, which ref lects a wide range of health problems.
The rationale for exploring the relationship between presenteeism and unemployment is the following.First, improving the employability of workers with health problems is a policy called "Support for Balancing Treatment and Work," which is strongly recommended by the Japanese government.Improvements in the prognosis for treatment of diseases have increased the length of time workers spend working while having health problems.Preventing unemployment among workers with health problems is an important issue facing the Japanese labor market, especially as the working population declines.Understanding the risk of unemployment among workers with health problems forms the basis for policymaking.Second, the assertion of the unemployment risk of presenteeism is important from the perspective of workers' quality of life.Presenteeism is often emphasized from the employer's perspective, viewing it as a decline in work productivity.However, for many workers, maintaining employment and earning a living are the primary purposes of work.Recognizing the link between presenteeism and unemployment is important from the perspectives of both work productivity for employers and the quality of life for workers.Third, presenteeism may signal when to intervene to maintain the employment of workers with health problems.Turnover of workers with health problems occurs due to a mismatch between work and performance, the signs of which cannot always be ascertained by diagnostic names or symptoms; presenteeism may serve as an indicator.
The COVID-19 pandemic has affected workers' experiences of presenteeism as well as their employment status.9][20] Lockdown and social distancing have resulted in public health challenges such as loneliness and stress. 21,22These challenges lead to worker presenteeism.In addition, the COVID-19 pandemic is having a serious impact on the global economy and employment.Disasters often exacerbate the job insecurity of those whose health and socioeconomic status are vulnerable.We reported that during the COVID-19 pandemic, workers who were vulnerable in their socioeconomic status-a high-risk group for unemploymentwere more likely to experience presenteeism. 23However, the association between presenteeism and unemployment among workers in the COVID-19 pandemic is not clear.In particular, there are few studies on the association between presenteeism status and unemployment, assessed not in terms of disease name or disease severity, but in terms of the degree of mismatch between health and work.The purpose of this study was to examine the association between presenteeism and resignations and unemployment during the COVID-19 pandemic.

Methods
A prospective cohort study was conducted starting in December 2020 and followed up until December 2021.This study targeted individuals between the ages of 20 and 65 who were employed full-time in Japan at the baseline.Participants completed questionnaires via the internet at the beginning and end of the study.All participants gave informed consent, and the study was approved by the ethics committee of the University of Occupational and Environmental Health, Japan (reference nos.R2-079 and R3-006).The study was done in accordance with national ethics guidelines and relevant regulations.
A protocol for this study was previously reported. 24Participants were employed workers between the ages of 20 and 65 at the time of the baseline survey.Sampling was based on region, occupation, and sex.Regions were divided into 5 levels according to COVID-19 infection level, covering 47 prefectures.Occupations were divided into office workers and non-office workers.Finally, a total of 20 blocks were created, consisting of combinations of 5 regions, 2 occupations, and 2 sexes.Participants were included so that each block would have the same number of participants.The original plan was to collect data for 30 000 participants overall, with a minimum of 1500 participants in each block.
The survey was commissioned to Cross Marketing Inc. (Tokyo, Japan).Approximately 600 000 of their 4.7 million preregistered monitors were sent an email request to participate in the survey.Of these, 55 045 participated in the initial screening, with 33 302 satisfying the final inclusion criteria.Of those 33 302 participants, 27 036 were included in the analysis, after excluding those judged as submitting untrustworthy responses.The following criteria were used to determine untrustworthy responses: extremely short response time (≤6 minutes), reporting extremely low body weight (<30 kg), reporting extremely short height (<140 cm), inconsistent answers to similar questions throughout the survey (eg, inconsistency on questions about marital status and area of residence), and wrong answers to a question used solely to identify unreliable responses ("Choose the third largest number from the following five numbers").Participants were required by the system to answer all questions, so there were no missing values.The follow-up survey was conducted in December 2021, 1 year after baseline.A total of 18 560 people (68.7%) participated in the follow-up after satisfying the inclusion criteria.

Evaluation of work functioning impairment
The Work Functioning Impairment Scale (WFun) was used to measure the degree of work function impairment. 25The WFun is a self-report outcome measure based on the Rasch model, and its validity has been thoroughly verified according to consensusbased standards for the selection of health measurement instruments (COSMIN). 26It consists of the following 7 statements: "I haven't been able to behave socially," "I haven't been able to maintain the quality of my work," "I have had trouble thinking clearly," "I have taken more rests during my work," "I have felt that my work isn't going well," "I haven't been able to make rational decisions," and "I haven't been proactive about my work."The participant responds to each statement using a 5-level scale: 1 = "not at all," 2 = "one or more days a month," 3 = "about one day a week," 4 = "two or more days a week," and 5 = "almost every day."The WFun score thus ranges from 7 to 35 points: the higher the score, the greater the degree of work functioning impairment.Based on previous studies, a WFun score of 14 to 20 was considered moderately impaired, and a score of 21 or higher was considered severely impaired work function. 27

Assessment of resignation and unemployment
In this study, we assessed resignation and unemployment experiences through 2 questions during the follow-up period.The first question inquired about experiences of resignation or job changes during the tracking period.Respondents were provided with the following 6 response options: I have not experienced resignation or job changes at all; I have experienced resignation or job changes (due to my own health reasons); I have experienced resignation or job changes (due to company downsizing, layoff, or contract expiration); I have experienced resignation or job changes (due to company bankruptcy, closure, or shutdown); I have experienced resignation or job changes (due to reaching the retirement age); and I have experienced resignation or job changes (for other reasons).
The second question inquired whether there was a period of unemployment when experiencing retirement or job changes.Respondents were provided with the following 5 response options: There was no period of unemployment; There was a period of unemployment, but I am currently employed; There was a period of unemployment, but I am currently self-employed (running a business, self-employment, etc); There was a period of unemployment, and I am currently unemployed (actively job seeking); There was a period of unemployment; and I am currently unemployed (not actively job seeking).
We defined those who responded that they resigned or changed jobs due to their own health reasons as "resignation for health reasons."Additionally, those with resignation or job change experiences other than health-related reasons were defined as "resignation for non-health reasons."Furthermore, individuals who had experienced resignation or job changes and had a period of unemployment were categorized as having "unemployment experience."

Statistical analyses
Age-sex-adjusted odds ratios (ORs) and multivariate-adjusted ORs were estimated using a multilevel logistic model nested in the prefecture of residence to take account of regional variability.We estimated ORs of work functioning impairment associated with resignation due to health reasons, due to other reasons unrelated to retirement, and experiencing unemployment, respectively.The multivariate model included age, sex, marital status, job type, industry type, income, education, smoking, alcohol drinking, number of employees in the workplace, and the incidence rate of COVID-19 by prefecture at baseline.In the model, "Government and organizations" with the largest number of people were used as the reference, and the other industries were adjusted as dummy variables.In the analysis with resignation for health reasons as the outcome, other resignations are not treated as outcomes, nor are they excluded from the analysis.The same is true for the analysis of resignation for non-health reasons as an outcome.A P value <.05 was considered statistically significant.All analyses were conducted using Stata (Stata Statistical Software: Release 16; StataCorp LLC, TX, USA).

Results
Table 1 shows baseline characteristics according to WFun score level.Compared with the group with the lowest WFun, the group with the highest WFun were of slightly higher average age (49.4 vs 46.6), were less likely to be married (58.6% vs 50.9%), and belonged to the lowest income groups (13.2% vs 19.1%).There were no reliable differences in occupational status or educational attainment, or in lifestyle habits such as smoking and drinking.
Table 2 shows the association of WFun with resignation experience and unemployment.WFun was associated with resignation due to health reasons.In the multivariate model, compared with the group with the lowest WFun, the OR of the group with a WFun of 14 points or more was 1.84 (96% CI, 1.48-2.29;P < .001)and the OR of the group with a WFun of 21 points or more was 2.99 (95% CI, 2.48-3.62;P < .001).
Similarly, WFun was also associated with resignation for other reasons unrelated to retirement.The multivariate model showed that the OR of the group with moderately impaired work functioning was 1.24 (95% CI, 1.13-1.35;P < .001)and the OR of the group with severely impaired work functioning was 1.61 (95% CI, 1.48-1.76;P < .001).

Discussion
The study showed that the greater the degree of work functioning impairment, the greater the risk of resigning from one's job due to both health and non-health reasons.Furthermore, the greater the level of work functioning impairment, the higher the risk of experiencing unemployment.These results are consistent with previous reports that workers with illnesses such as rheumatoid arthritis, musculoskeletal disorders, mental health disorders, and cardiovascular disease, are associated with long-term sick leave and early retirement. 8,9,28,29resenteeism is of growing interest to Japanese companies in accordance with the government-led so-called "health and productivity management strategy". 30However, this interest is generally focused on the decline in productivity caused by presenteeism, 10 a natural bias from the employer's perspective given that reduced productivity is a strong business concern.In reality, however, presenteeism is not actively managed in Japanese companies in terms of long-term negative impacts on, for example, workers' quality of life and unemployment.Although in Japan routine health checkups are required by law, there is little incentive to actively manage presenteeism, which encompasses multiple health issues including symptoms and complaints that are sometimes not even diagnosed.In addition, workers who leave the workforce are unlikely to interest employers because the financial cost shifts from the company to somewhere else, for example, social welfare. 31here are various possible reasons why resignations increase when workers experience presenteeism.People with health problems experience a variety of work disabilities. 13,32,33Employees who are unable to perform certain tasks may have reduced work hours, changes in employment, and ultimately an increased risk of exiting the labor market. 13Additionally, unhealthy individuals may have difficulty obtaining secure employment and are more likely to be employed by companies with unstable business conditions. 34,35In such cases they may be forced to resign or more likely made redundant independent of their health status.
Whereas some illnesses are known to be associated with longterm sick leave and early retirement, 8,9,28,29 there is less evidence on the relationship between the degree of work functioning impairment and resignations in Japan. 36Because the degree of work functioning impairment ref lects a mismatch between job requirements and health status, 10,11 it cannot be evaluated solely on the basis of diagnosis or severity of a given disease.For example, a worker with back pain may be unable to tolerate muscle work but could cope with a desk job.In addition, evaluations based on, for instance, the glycosylated hemoglobin for diabetes or the simplified disease activity index for rheumatoid arthritis, are appropriate for assessing disease severity, but they do not indicate the degree of difficulty a worker experiences while performing his or her job.Therefore, we argue for using multiple tools to measure presenteeism, for a comprehensive assessment of health-induced work difficulties in people with various illnesses and severities.
In this study, we have demonstrated associations between 3 distinct outcomes-resigned due to health reasons, resigned for non-health reasons other than retirement, and experienced unemployment-and their relationship with presenteeism.Although these outcomes represent different phenomena, they are not mutually exclusive but often overlap.Identifying consistent associations across these similar yet distinct indicators serves to underscore the robustness of the associations in question.If presenteeism were to serve as a turning point leading to retirement or career changes, " resigned due to health reasons" would be the most direct consequence of presenteeism.However, it is essential to recognize that the reasons behind an individual's resignation are often multifaceted.Even when individuals are experiencing health issues, they may not attribute their resignation solely to health problems.Focusing solely on "resignation due to health reasons" as an outcome could potentially underestimate the sensitivity of the relationship with presenteeism.Indeed, ORs were found to be most substantial when considering this outcome among the three.Nevertheless, restricting the outcome solely to "resignation due to health reasons" might overlook the extent of this issue.Some individuals who indicated reasons other than health for their resignation might still experience direct or indirect impacts of presenteeism, and in practice health issues can be one of the factors leading to resignation.Thus, we examined the relationship between presenteeism and retirement due to non-health reasons, acknowledging the potential for direct and indirect associations.Indeed, a relationship between non-healthrelated resignation and presenteeism was observed, suggesting that presenteeism may encompass indirect issues affecting job continuation beyond health concerns.Unemployment is defined as the state of not being employed while actively seeking employment.This state of not working can encompass both positive and negative circumstances.However, unemployment carries negative implications, both individually and societally.In this study, we used unemployment as an outcome representing a negative non-employment state, and we demonstrated its association with presenteeism.
This study was conducted in Japan when the COVID-19 pandemic was expanding. 24Many Japanese companies were imple-menting various infection control measures to prevent the spread of COVID-19, including maintaining physical distance, wearing masks, basic hygiene (eg, hand washing), daily health checks, and telework.One measure was restricting employees from coming to work when they were sick.8][39][40] In addition, across the world interruptions to medical treatments have been caused by the COVID-19, including in Japan. 18Interruptions and delays in treatment may exacerbate pre-existing health conditions and increase complications, which may further increase the incidence of sickness presenteeism.In parallel, the COVID-19 pandemic has led to precarious employment conditions in Japan. 41During the pandemic, workers in a less secure socioeconomic situation were more likely to experience presenteeism. 23Vulnerable socioeconomic conditions are themselves also a risk factor for job resignation and unemployment.In this study, even after controlling for socioeconomic factors such as income, education, and firm size, work functioning impairments were still found to increase the risk of resigning and unemployment, thus creating a double whammy for those with socioeconomic insecurity.
Reducing employment disadvantage through early intervention in cases of work functioning impairment is a major challenge. 31However, no specific scheme for this purpose has been forthcoming.Adjustment of the working environment is essential for people with health problems to continue working. 12Workers' health status and their ability to work can be modified to improve and maintain continuity of employment, for example, by adjusting workload and content, and by providing benefits such as sick leave for medical treatment and recuperation. 38,42For some conditions, maintaining the ability to work has been achieved through clinical intervention. 43However, many Japanese workers are known to avoid clinical intervention for pain and musculoskeletal disorders, 44 both conditions that can lead to presenteeism.Management of presenteeism requires both occupational and clinical support.
We note some limitations of this study.First, all the assessments were based on self-reports.However, we do not expect many serious memory errors or recall biases regarding changes in employment over the relatively short duration of the study (1 year).Second, presenteeism and employment situations experienced by workers may be different under COVID-19 pandemic conditions than in a non-pandemic period.Conceivably, the association could be even more pronounced.Third, we did not determine whether any period of unemployment was due to health reasons.Unemployment may occur simply because of the managerial situation of the employer.Nevertheless, because this study has revealed a greater likelihood of unemployment when the degree of work dysfunction is higher, the association may in fact be stronger than it appears.Fourth, because this study is an internet survey, the representativeness of the subjects is uncertain.However, if the association between presenteeism and unemployment is true, the association is usually warranted, even within a biased population.

Conclusion
In conclusion, workers with work functioning impairment for health reasons were at increased risk of resigning from their job or unemployment.Obviously, the risk of resignation due to health reasons was particularly high.Further development of health management strategies for people with work functioning impairment is needed to reduce their disadvantages in regard to employment.

Table 1 .
Baseline characteristics and unemployment status at follow-up by Work Functioning Impairment Scale (WFun) score level.

Resign for non-health reasons (other than retirement) b
a Showing the values for the top 5 industries with the highest number of subjects among the 22 sectors.b Information on unemployment is shown at the time of the follow-up.

Table 2 .
Odds ratios (ORs) of work functioning impairment associated with resignation due to health reasons, due to other reasons unrelated to retirement, and experiencing unemployment.The model included age, sex, marital status, job type, industry type, income, education, smoking, alcohol drinking, number of employees in the workplace, and the incidence rate of COVID-19 by prefecture at baseline.
b P for trend.